Rectovaginal Fistula Research Articles

Understanding the anatomical basis of anorectal fistulas and their surgical management: exploring different types for enhanced precision and safety.

Anorectal fistulas remain one of the most challenging conditions in colorectal surgery and require precise anatomical knowledge for successful management. This comprehensive review synthesizes the current evidence on the anatomical foundations of fistula development and treatment, particularly focusing on the cryptoglandular hypothesis and its clinical implications. A systematic analysis of the recent literature has examined the relationship between anatomical structures and fistula formation, classification systems, diagnostic modalities, and therapeutic approaches. The review revealed that anatomical considerations fundamentally influence treatment outcomes, with modern imaging techniques achieving up to 98% accuracy in delineating fistula anatomy. Key findings demonstrate that surgical success rates vary significantly based on anatomical complexity: 92-97% for simple fistulas versus 40-95% for complex cases using sphincter-sparing techniques. Emerging minimally invasive approaches and regenerative therapies, including mesenchymal stem cells, show promising results with 50-60% healing rates in complex cases. Special considerations are needed for complex cases such as Crohn's disease-related and rectovaginal fistulas. This review provides surgeons with an evidence-based framework for selecting optimal treatment strategies based on anatomical considerations, emphasizing the importance of preserving the anal sphincter function while achieving complete fistula eradication. Integrating advanced imaging, surgical techniques, and emerging therapies offers new possibilities for improving patient outcomes. This review aimed to bridge the gap between anatomical knowledge and practical surgical application, enhance clinical decision-making, and improve patient outcomes in anorectal fistula management.

P0273 Advances in understanding and managing perianal Crohn’s disease: Insights from the new classification system and results from a single-center series.

Abstract Background A new classification for perianal disease has been published to assist clinicians in identifying and treating this phenotype (1). However, no studies have evaluated its use in real-world settings. We analyzed the distribution and appropriateness of perianal fistula management in a single center. Methods This was a retrospective and unicentric study. Crohn´s disease patients with perianal fistulizing phenotype were included. Non fistulizing perianal disease, recto-vaginal fistulae, ileoanal pouch-related fistula or patients without follow-up were excluded. Fistulas were identified according to the new classification system. Baseline characteristics, the applied treatment, and the probability of progression were analyzed. Therapeutic success and management errors were based on consensus recommendations. Descriptive statistics were applied. Results Over 1068 patients diagnosed with Crohn´s disease a total of 267 patients presented perianal disease (25%). Finally, 184 patients were included (the majority of excluded patients were due to non fistulating perianal disease or rectovaginal fistulae). Basal characteristics are shown in Table 1. Perianal fistulae distribution according to new classification is presented in Figure 1. Thirty six patients (20%) changed fistulae class after a median time of 44 months (range 20-265): class 2b (11 patients, 31%), class 2c (16 patients, 44%), class 3 (7 patients, 20%). No patients presented class 4 fistulae during period evaluation. The treatment employed was: seton plus biological therapy (41%), biological therapy plus reparative surgery (22%), seton replacement alone (10%), biological therapy alone (4%), proctectomy (3%) and defunctioning ostomy (3%). No treatment was administered to 17% of cases. In 44% of cases, there were management errors according to established recommendations. These were: no reparative surgery (40%), no biological therapy use (35%), no defunctioning ostomy (15%). It was significantly higher in the case of type 2a class (37 vs 7%, p 0.001). Despite this findings, 78% of cases achieved the therapeutic goal according to new recommendations. Conclusion Class 2 perianal fistulae are the most common and where management errors may occur. However, the majority of patients achieve the therapeutic goal.

Fistulae Secondary to Vaginal Pessary Use for Pelvic Organ Prolapse: A Systematic Review.

Urogenital and rectovaginal fistulae are rare complications of pessary use for pelvic organ prolapse (POP). This systematic review investigates the prevalence of these complications in patients using pessary for POP, potential risk factors and approaches to their investigation and management. All studies in English reporting urogenital or rectovaginal fistulae secondary to pessaries for POP were eligible for inclusion. AMED, CINAHL, MedLine, Scopus and Web of Science databases were searched from inception to March 2024. Risk of bias was assessed using validated tools: Murad et al.'s tool for case series/reports and ROBINS-I for non-randomised studies. Quantitative synthesis of descriptive statistics and narrative summary were performed. Two retrospective studies and 60 case series/reports were included, describing 76 fistulae (34 urogenital, 42 rectovaginal). The retrospective studies estimated the prevalence of fistulae to be 3%. Of reported fistulae, 45% occurred with Gellhorn, 16% with ring, 11% with shelf and 9% with cube pessaries. Fifty percent were associated with neglected pessary care. Conservative management resulted in size reduction or resolution in 69% of fistulae: this approach should be considered. Vaginal (88%) and abdominal (100%) vesicovaginal fistula repairs were successful. Diverting ostomies were popular for rectovaginal fistulae but often resulted in permanent stoma without reducing mortality, recurrence or repair failure. Colpocleisis represents an effective procedure for managing co-existing POP. The prevalence of fistulae from pessary use is likely < 1% but may rise to 3% with risk factors present, including Gellhorn pessaries and neglected care. Both conservative and surgical management are viable treatment options.

The Role of Graciloplasty in the Treatment of Obstetric Anal Sphincter Injury with Subsequent Fecal Incontinence and Recurrent Low Recto-Vaginal Fistula: A Case Report

The Role of Graciloplasty in the Treatment of Obstetric Anal Sphincter Injury with Subsequent Fecal Incontinence and Recurrent Low Recto-Vaginal Fistula: A Case Report

Complications in transgender patients undergoing vaginoplasty procedure.

To report the statistics of complications in gender reassignment surgery (vaginoplasty) observed in the first surgical center in Mexico for public transgender surgery. We conducted a descriptive, observational study of patients treated and postoperatively underwent vaginoplasty surgery in the period 2019 to 2022. Intraoperative, immediate and late complications were evaluated. Intraoperative complications were taken as: rectal perforation and bleeding. Immediate complications: wound dehiscence, hematoma, and necrosis of the vaginal segment. Late complications: urethrovaginal fistula, rectovaginal fistula, and stenosis of the vaginal introitus. Twenty-two patients who underwent vaginoplasty with inversion of the foreskin were evaluated. Regarding immediate complications, the most frequent were alterations in scarring and tissue integration, being necrosis of the vaginal segment the most frequent. As for late complications, only vaginal prolapse and urethral stricture were found. Foreskin inversion vaginoplasty is the most widely used and safest technique worldwide, above colovaginoplasty and peritoneal vaginoplasty techniques, and fortunately serious complications are rare. In our report, tissue alterations were the common ones and that is secondary alteration of vascular integration and devascularization factors during the dissection.

An unexpected link: A unique presentation of colovaginal fistula secondary to post-hysterectomy adhesions in an elderly patient

An unexpected link: A unique presentation of colovaginal fistula secondary to post-hysterectomy adhesions in an elderly patient

Treatment of both rectovaginal fistula and anal stricture with single skin flap.

Treatment of both rectovaginal fistula and anal stricture with single skin flap.

Current practice regarding the diagnosis and treatment of anorectal malformations in female patients: a multicenter questionnaire survey in Japan.

This study aimed to investigate the current practices in the diagnosis and surgical management of anorectal malformations (ARMs) in female patients in Japan, specifically focusing on anovestibular fistula (AVF), rectovaginal fistula (RVF), and persistent cloaca (PC). An anonymous online survey was conducted with 61 institutional members of the Japanese Study Group for Anorectal Anomalies. Sixty-one institutions (100%) completed the survey. For AVF, fistulography/vaginography was the most common diagnostic method (98.4%), and anorectoplasty was usually performed at 3-6 months of age (86.9%) using anterior sagittal anorectoplasty (62.3%) or anal transposition (39.3%). Distal colostography (100%), MRI (71.7%), and cystscopy/urethroscopy/vaginoscopy (83.3%) were commonly used for PC. Patients with PC underwent anorectoplasty at 7-24 months (93.3%), predominantly posterior sagittal anorecto-urethro-vaginoplasty (PSARUVP) (41.7%), or laparoscopy-assisted anorectoplasty (LAARP) (43.3%). A subgroup analysis revealed that PSARUVP used blunt dissection (70.0% vs. 28.6%, p < 0.05) and visual confirmation by opening the rectum (80.0% vs. 4.8%, p < 0.001) significantly more often than LAARP for PC. This nationwide survey revealed distinct patterns in the diagnostic timing and surgical approaches for female ARMs in Japan, highlighting the varying preferences in fistula management techniques across different types of malformations.

Retrospective study of congenital anomalies of cattle and goats in selected areas of Mymensingh and Netrokona districts of Bangladesh

Background: Ruminants, especially cattle and goats, are prone to a wide range of congenital anomalies influenced by dietary, genetic, or environmental factors. Understanding these anomalies is essential for improving animal health and productivity. This study aimed to identify congenital defects in calves and kids across three upazilas in Bangladesh and to analyze their occurrence concerning breed, sex, and season. Methods: Retrospective data on species, sex, breed, and season (summer, rainy, and winter) were collected from the register books of the Veterinary Teaching Hospital (VTH), Bangladesh Agricultural University, Mymensingh; Upazila Veterinary Hospital, Mymensingh Sadar, Mymensingh; and Upazila Veterinary Hospital, Kendua, Netrokona, spanning July 2013 to June 2023. Among 1159 cases, 1050 involved calves, and 109 involved kids. Data were analyzed using the Chi-square test in SPSS version 20. Results: The most prevalent congenital anomaly identified was umbilical hernia (52.6%), followed by dermoid cyst (21.4%), atresia ani (15%), persistent urachus (5.8%), knuckling (3.4%), and rectovaginal fistula (1.8%). Both cattle (55.8%) and goats (57.8%) showed a higher prevalence of anomalies in males. Specifically, atresia ani, dermoid cyst, and umbilical hernia were more common in male calves, with occurrences of 62.4%, 57.35%, and 52.9%, respectively, while persistent urachus was found predominantly in males (80.3%). Knuckling was slightly more prevalent in females (52.8%), and rectovaginal fistula occurred exclusively in females. Regarding breed, persistent urachus was more frequently observed in indigenous breeds (55.7%), while atresia ani and rectovaginal fistula showed high frequencies in indigenous calves, with 65% and 63.2%, respectively. Conversely, dermoid cyst, umbilical hernia, and knuckling were more common in crossbred animals, occurring at frequencies of 55.6%, 60%, and 55.6%, respectively. Seasonal variations also played a role, with atresia ani most frequent in the rainy season (35%), while all other anomalies showed their lowest occurrences during this season. Persistent urachus was most prevalent in winter (41%), while dermoid cyst, umbilical hernia, and rectovaginal fistula were most common in summer, with frequencies of 38.2%, 39.7%, and 42.1%, respectively. Additionally, cattle exhibited a higher occurrence of congenital anomalies in crossbred calves during summer, whereas Black Bengal kids were more affected during winter. Conclusion: Calves exhibited a higher occurrence of diverse congenital anomalies, with umbilical hernia being the most common, while kids were predominantly affected by atresia ani. Anomalies were more frequently observed in male animals and during the summer season.

Conservative management of a rectovaginal fistula caused by a Gellhorn pessary. A case report

Conservative management of a rectovaginal fistula caused by a Gellhorn pessary. A case report

Comparison of Complications and Outcomes of Very Low Anterior Resection (VLAR) Versus Intersphentric Resection (ISR) In Patients with Rectal Cancer.

Colorectal cancer is a cancer that starts in the colon or rectum, which are part of the digestive system. Intersphincteric resection (ISR) and very low anterior resection (VLAR) are surgical procedures used in rectal malignancy. We aimed to compare postoperative complications and recurrence after VLAR and ISR techniques in patients with rectal cancer. In this retrospective study, 80 rectal cancer patients who underwent VLRA and ISR in Shahid Faghihi, and Abu-Ali Sina Charity Hospitals, Shiraz, Iran from 2019 to 2023 were enrolled. Eligible patients were divided into two groups based on the type of operation. One group underwent VLAR (n=40) and the second group of patients underwent ISR(n=40). Postoperative complications and outcomes were compared between the two groups. The mean age in VLAR and ISR groups was 52.8±14.3 and 54.3±11.6 years, respectively. Low anterior resection syndrome was not significantly different between the two groups (P=0.39). Postoperative fecal incontinence was observed in 27.5% and 22.5% of VLAR and ISR groups, respectively. This difference was not statistically significant (P=0.91). Rectovaginal fistula was reported in 2.5% of patients in both groups (P=0.61). There was no difference in postoperative complications in VLAR and ISR techniques. Considering the lack of significant difference in the complications of the two surgical groups, it is suggested to choose the surgical method based on the location of the tumor.

Postoperative rectovaginal fistula: stoma may not be necessary—a French retrospective cohort

BackgroundPostoperative rectovaginal fistula leads to a loss of patients’ quality of life and presents significant challenges to the surgeon. The literature focusing specifically on postoperative rectovaginal fistulas is limited. The objective of the present study is to identify factors that can enhance the success of the management of this postoperative rectovaginal fistula.MethodsThis retrospective multicentric study included all patients undergoing surgery for rectovaginal fistulas, excluding those for whom the etiology of rectovaginal fistula was not postoperative. The major outcome measure was the success of the procedure.ResultsA total of 82 patients with postsurgical fistulas were identified, of whom 70 were successfully treated, giving a success rate of 85.4%. On average, these patients required 3.04 ± 2.72 interventions. The creation of a diversion stoma did not increase the success rate of management [odds ratio (OR) = 0.488; 95% confidence interval (CI) 0.107–2.220]. Among the 217 procedures performed, 69 were successful, accounting for a 31.8% success rate. The number of interventions and the creation of a diversion stoma did not correlate with the success of management. However, direct coloanal anastomosis was significantly associated with success (OR = 35.06; 95% CI 1.271–997.603; p = 0.036) as compared with endorectal advancement flap (ERAF). Other procedures such as Martius flap did not show a significantly higher success rate.ConclusionThe creation of a diversion stoma is not necessary in closing a fistula. ERAF should be considered as a first-line treatment prior to proposing more invasive approach such as direct coloanal anastomosis.

S3172 A Rectovaginal Fistula Associated With Squamous Cell Carcinoma of the Rectum

S3172 A Rectovaginal Fistula Associated With Squamous Cell Carcinoma of the Rectum

Evagination method for rectovaginal fistulas

AIM: to assess early and late results of the evagination method for the treatment of rectovaginal fistulas (RVF) in patients with anal incontinence due to muscle defect in the anterior semicircle. PATIENTS AND METHODS: the study included 45 patients. The prevailing etiology of RVF was delivery lesion in 19/45(42.2 %). The median follow-up was 6 (4; 8.5) months. On day 30 after surgery, the outcome was assessed clinically. Late outcomes were assessed in all patients 3–12 months including clinical control, transanal ultrasound and sphincterometry. RESULTS: recurrence occurred in 9/45 (20 %) patients. The significant improvement of continence was revealed: in mean pressure in rest (p = 0.004), in maximum contraction pressure (p &lt; 0.0001), in Wexner incontinence score (p &lt; 0.0001). With a fistula opening less than 16 mm, the recurrence risk increases (p = 0.0003). CONCLUSIONS: the evagination method is effective option in extent septal defects and correcting additional analsphincter insufficiency.

Rectovaginal fistulas : Differentiated diagnostics and treatment

Rectovaginal fistulas (RVF) represent less than 5% of anorectal fistulas. The classification of RVF is based on the localization (low vs. high) and the etiology. The most frequent causes of RVF are birth trauma, Crohn's disease, previous surgery and pelvic irradiation. In most cases a clinical diagnostic assessment is sufficient. Additionally, endosonography is areliable tool to detect sphincter defects. Computed tomography (CT) and magnetic resonance imaging (MRI) are reserved for special situations (e.g., RVF related to anastomotic leakage, after pelvic irradiation or associated with complex perianal fistulizing Crohn's disease). The surgical treatment is primarily oriented to the localization and etiology. Surgical techniques range from local procedures (e.g., endorectal advancement flap repair, transvaginal or transperineal closure) up to more invasive tissue interposition (e.g., bulbocavernosus muscle fat tissue flap or transposition of the gracilis muscle). In "high" RVF transabdominal approaches such as coloanal anastomosis, pull through procedures or omental interposition are indicated. All surgical procedures show high recurrence rates. Several operations are mostly necessary and a stoma creation is often required.

Primary mucinous adenocarcinoma intestinal type of the vulva arising at site of prior vulvar Crohn’s disease: A case report and review of the literature

Introduction: Vulvar mucinous adenocarcinoma is a rare subtype that likely arises from atopic gastrointestinal tissue. The evaluation and treatment of this condition often requires a multidisciplinary approach. Case Report: Our patient is a 55-year-old female with a history of Crohn’s disease who initially presented with a painless vulvar mass associated with occasional bleeding. Notably, the mass presented at the site of a prior rectovaginal fistula. A vulvar biopsy was performed with pathology consistent with intestinal type mucinous adenocarcinoma. Further workup was notable for imaging showing retroperitoneal and pelvic metastatic lymphadenopathy, hypermetabolic liver and bony metastases, and pulmonary nodules concerning for metastases. Following discussion at tumor board, the patient was recommended treatment with 5-fluorouracil, leucovorin, oxaliplatin (FOLFOX), and bevacizumab. Unfortunately, prior to starting chemotherapy, the patient presented to the emergency department with dizziness and weakness and was found to have brain metastases. She ultimately elected to be discharged home on hospice care. Conclusion: Vulvar mucinous adenocarcinoma is a rare subtype tumor with limited literature on treatment options. For these rare cases, clinicians can consider treatment modalities for colon carcinomas rather than vulvar carcinomas.

Anorectal Malformation Patients in Australia and Europe: Different Location, Same Problem? A Retrospective Comparative Registry-Based Study

Anorectal malformations (ARM) encompass a spectrum of rare congenital defects of the rectum and anus, requiring specialized reconstructive surgery. To improve epidemiological and clinical research in rare diseases such as ARM, collaborative efforts and patient registries are key.This retrospective study pools clinical data over a 30-year period from two ARM patient registries (The Royal Children's Hospital (RCH) in Melbourne, Australia, and the ARM-Network Consortium in Europe). It aims to draw comparisons on demographics, management, and outcomes between ARM patients in Australia and Europe.A total of 2947 ARM patients were included in the analyses. The RCH cohort had more complex ARM types (including rectal atresia and recto-vaginal fistula) and more associated anomalies, specifically skeletal, cardiac, and/or trachea-esophageal, than ARM-Net patients. Other patient characteristics were similar. Treatments clearly differed between the groups. European surgeons favoured the PSARP approach for both less complex and more complex ARM types, where Australian surgeons opted more often for cutback surgery in less complex, and laparoscopic assistance in more complex types. Complications were differently distributed, with less complications after LAARP and more after PSARP at RCH, compared to ARM-Net. While RCH patients more often required a redo, ARM-Net patients more commonly underwent anal dilatations.Anorectal malformation patients in Australia and Europe had minor differences in disease characteristics, and both operative and medical approaches differed. Joint efforts such as the present study emphasize the importance of collaboration to elucidate areas of improvement where surgeons may learn from each other across the world, ultimately improving patient outcomes. Type of StudyOriginal Research. Level of EvidenceIII.

Use of Vaginoscopy after Vaginoplasty in Individuals with Congenital Adrenal Hyperplasia

Study ObjectiveTo explore the use of exam under anesthesia with vaginoscopy (EUA-V) following vaginoplasty in patients with congenital adrenal hyperplasia (CAH). DesignRetrospective cohort MethodsAn IRB-approved retrospective chart review was performed of the post-surgical follow-up care of all patients diagnosed with classical CAH who sought care at a tertiary children's hospital from 2000-2017 and had undergone vaginoplasty at that institution. ResultsTwenty-six patients met inclusion criteria. The median age at vaginoplasty was 1.25 years (IQR: 0.67, 9). Median post-surgical follow-up was 5.5 years (IQR: 1.5, 9). Twenty six EUA-Vs were performed, on 22 patients. Four were for complication assessment (rectovaginal fistula (1); urethrovaginal fistula (3)—on the same patient). The remaining 22 EUA-Vs, performed on 20 patients with two each undergoing two EUA-Vs, were planned for routine evaluation of vaginal patency. They were done a median of 0.67 years (IQR: 0.25, 2) following surgery and at a median of 6.67 years of age (IQR: 1.75, 12). Of these, five EUA-Vs identified stenosis in five patients (25%), a median of 0.91 years (IQR: 0.5, 7) after surgery, at a median age of 8.42 years (IQR: 2, 10.92). Of the four who did not undergo EUA-V, one had stenosis on clinical exam with ultrasound-verified hematocolpos. The remaining three were all prepubertal at last follow-up. ConclusionThe majority of CAH patients following vaginoplasty underwent routine EUA-V, roughly a quarter of which detected stenosis. EUA-Vs may play a beneficial role in routine post-op care following vaginoplasty in patients with CAH.

Abdominal Hartmann reversal versus combined transanal/abdominal approach: Outcomes and technical notes

Background: Hartmann’s reversal (HR) is one of the most technically challenging operations in colorectal surgery. A small percentage of HR operations are performed laparoscopically. The pelvic dissection is the key point of the procedure and can be demanding when the rectal stump is extraperitoneal and if the pelvic condition is complex. Methods: A retrospective observational single-center study was designed to analyze the outcomes of patients with an extraperitoneal rectal stump who underwent HR from January 2015 to December 2020 at IRCCS Sacro Cuore Don Calabria Hospital in Negrar of Valpolicella. The patients were divided into two groups: group 1 underwent a purely abdominal Hartmann’s reversal (A-HR) and group 2 underwent a combined transanal and abdominal Hartmann’s reversal (TA-HR). Results: Forty-two patients were divided into the groups as follows: 22 (52.3%) patients in the A-HR group versus 20 (47.62%) patients in the TA-HR. The transanal approach did not significantly affect the operative time. The rate of rectovaginal fistula was higher in the TA-HR group (65% vs. 4.5%). The anastomosis was performed mechanically in all A-HR cases and 50% of TA-HR patients (P &lt; 0.01). No difference in temporary stoma creation was found. The rate of complications was lower in the TA-HR group (P = 0.05). The A-HR group was statistically significantly associated with redo surgery (P = 0.04). Stoma failure rate at the end of the follow-up did not differ between the two groups. Conclusions: Transanal Hartmann reversal seems to be a safe approach in patients with a complex pelvis and extraperitoneal rectal stump.

Protective defunctioning stoma in bowel segmental resection at the time of total hysterectomy for endometriosis: when less is more

PurposeTo compare postoperative complications in women undergoing total hysterectomy with segmental resection (TH-SR) for intestinal endometriosis with or without protective defunctioning stoma (PDS) confection.MethodsRetrospective cohort study conducted at the Gynecologic department of University Hospital of Lille (France) from January 2008 to January 2022 in patients undergone TH-SR for bowel endometriosis.Results100 women were considered for the analysis. PDS were performed in 56 women. The rate of rectal resections was significantly higher in the PDS group (p = 0.03). The mean operative time, AAGL scores and length of hospital stay were significantly higher in the PDS group (p = 0.002). The rate of grade III complication according to Clavien-Dindo classification was higher in the PDS group (p = 0.03). Among digestive complications, one case of anastomosis leakage (1.8%) and one case of recto-vaginal fistula (2.3%) was recorded in the non-PDS group, 4 cases of anastomosis stenosis were recorded in the PDS group (7.1%). Persisting bladder atony requiring self-catheterization over one month was the most common disturb (4.6% in the non-PDS group and 7.1% in the PDS group, p = 0.58). The distance of digestive lesion from anal margin was the only risk factor for digestive complications, persistent bladder atony, Clavien-Dindo IIIA and IIIB complications at the multivariate analysis (p = 0.04 and p = 0.06 respectively).ConclusionNo statistically significant differences were found in the rate of digestive complications in case of total hysterectomy and concomitant segmental resection when performing or not preventing stoma.